Breath of Fresh Air

Many of us have a touch of “sinus” from time to time. But for Sandra Butcher, a sinus problem turned into a miserable bout of chronic rhinosinusitis. After two-and-a-half years of discomfort, medication and doctor visits, Sandra’s story ended happily with the help of ear, nose and throat doctor Martin J. Citardi, MD, of The University of Texas Health Science Center at Houston (UTHealth).

Sandra, her husband Larry and their three daughters moved to Corpus Christi in 1979 from California when Larry got a job in the oil fields. Aside from the occasional head cold, Sandra, 68, who works at a Ford dealership, had always enjoyed good health — and playing sports.

“I like to do it all — baseball, basketball, kickball, snowmobiling, golf, aerobics,” Sandra says. The couple also enjoys dirt-track racing. And Sandra’s a power lifter: Eight years ago, she set a record for bench-pressing 137 pounds. She kept going strong well into her 60s — until 2009, when she went to her doctor with what felt like a cold.

Sinuses on strike

“I kept having that tickle in the back of my throat, and I’d cough and cough,” Sandra recalls. “I was very congested — very, very congested.”

As her symptoms went on, two rounds of antibiotics to knock out a potential bacterial infection didn’t help. Neither did decongestants. Sandra began to have trouble hearing. She even suffered asthma flare-ups that frightened Larry and sent her to the emergency room.

Sandra began visiting an allergist for daily shots. She and Larry bought new bedding to cut down on allergens, and they banished their beloved dogs, Zippy and Kinser, from the house.

“Did I snore? Just ask my husband!” Sandra says.

“We’ve got two bull mastiffs, and she outdid ‘em!” Larry adds.

Increasingly desperate, Sandra visited a nearby ear, nose and throat specialist, who operated. But the surgery didn’t leave her feeling much better. Another specialist offered contradictory advice about medications. In the meantime, her sinuses were full, she had to breathe through her mouth, and she felt tired all the time. She gave up sports.

“I was miserable,” Sandra recalls. “At night, I slept propped up. On weekends, I would sit in my chair and sleep — I couldn’t do anything. I just barely made it to work every day.”

What is chronic rhinosinusitis?

Chronic rhinosinusitis (CRS) is an uncomfortable condition in which the nasal passages and the surrounding sinuses — hollow, bony cavities — become inflamed and swollen and stay that way for 12 weeks or more without responding to treatment.

Larry and Sandra Butcher

Normally, the sinuses and nasal passages produce a small amount of mucus that keeps them moist and catches dust and bacteria. This mucus drains into the nose, where it is swallowed or blown out through the nostrils. If inflammation swells the sinuses, that drainage may be blocked, so mucus can build up and get infected.

Over time, it becomes hard to breathe through the nose. Smell and taste can grow dull. Depending on which sinuses are involved, the face can become tender to the touch over the cheekbones or forehead. Some people suffer pain in the ears, throat or upper jaw; bad breath; cough; fatigue; and even nausea.Constantly uncomfortable, people with CRS may find themselves unable to do their ordinary activities.

Though not usually life-threatening, the condition can erode quality of life as badly as serious chronic diseases like diabetes and congestive heart failure.

“It’s like having a bad head cold, every day, without end,” notes Citardi, professor and chair of otorhinolaryngology-head and neck surgery at UTHealth Medical School and chief of otorhinolaryngology (ear, nose and throat) at Memorial Hermann-Texas Medical Center. “Also, you’re constantly going back and forth to physicians, and being in that sick role magnifies the sense of not being well.”

Sandra can relate. “I thought, ‘Oh my God, am I going to have to live the rest of my life like this?’” she recalls. “I was really depressed.”

Sinus surgery

Because her condition did not improve, Sandra’s ENT surgeon finally referred her to Citardi. In addition to being a board-certified otorhinolaryngologist (also known as an ear, nose and throat doctor, or ENT), he is trained in the subspecialty of rhinology, or the care of the nose and sinuses. He is one of three rhinology subspecialists at UTHealth’s Texas Sinus Institute.

“Most of our patients have had one or more previous surgeries,” Citardi says, “so we are often the last stop for someone like her.” He examined Sandra’s sinuses with a special camera and saw scarred pockets, inflamed sinus linings, polyps and abnormal secretions too thick to drain.

Based on his examination, his conversation with Sandra and Larry, and a review of the medical record, Citardi concluded that Sandra would benefit from a procedure called image-guided functional endoscopic sinus surgery (IG-FESS). This minimally invasive operation allows the surgeon to clean the sinuses, remove debris and open up blocked passages so that secretions can drain again. It uses slender instruments that fit through the nose, so the surgeon doesn’t have to cut the skin. Often, the patient goes home on the same day as the procedure.

“After we do that,” Citardi says, “then all the other medical treatments work better.”

As soon as she awoke from anesthesia, Sandra could tell the difference. “I felt so much better. It was like night and day,” she recalls. “I didn’t have that pressure on my chest anymore. I could breathe.”

Surgery for CRS isn’t a complete cure. But because operations like IG-FESS can fix the “plumbing” problem in the sinuses and nasal passages, it can make treatment for infection or inflammation far more effective.

With follow-up medical treatments, including steroids and topical antibiotics, and careful attention to flare-ups, Sandra has done well.

“After the surgery and my next couple of visits, every time I saw Dr. Citardi, I just give him a big old hug because he changed my life. He really did,” Sandra says. She pauses. “I get emotional,” she adds.

Origins and treatment

Doctors don’t fully understand the causes of CRS. Years ago, they emphasized antibiotics because infection was thought to be the underlying problem. Today, it is believed that CRS results from out-of-control inflammation in the sinus lining. Patients with CRS often have asthma, a disorder with similar inflammation in the lining of the lungs. Some patients with CRS are also allergic to inhaled materials, although it is best to think of these two conditions as separate processes that may occur together.

Some CRS patients also have nasal polyps, or bulky growths in the sinuses and nose. Allergic fungal rhinosinusitis (AFRS) is a special type of CRS with nasal polyps that includes an inflammatory reaction to common fungi.

Treatment starts with making sure the diagnosis is correct — and with not mistaking less serious conditions for CRS. “Most episodes of nasal symptoms are self-limiting and probably do not need much treatment,” Citardi notes.

For example, acute viral infections of the nasal lining (acute rhinitis, or a “cold”) are common, but they get better with simple supportive measures. About 2 to 5 percent of patients with acute rhinitis develop an acute bacterial sinus infection, which is best treated with oral antibiotics. Inhalant allergies, also known as allergic rhinitis (allergic inflammation of the nasal lining), respond well to treatment with oral and spray antihistamines and nasal steroid sprays.

CRS is different. CRS symptoms include three or more months of nasal congestion, facial pressure and/or foul nasal discharge. The sense of smell may also be affected. Treatments include steroid sprays and pills as well as antibiotics. Flushing the sinuses with a saline solution can help.

If these medical treatments don’t work, then a patient with persistent CRS may be a candidate for sinus surgery. Functional endoscopic sinus surgery (FESS) was introduced 30 years ago, and since then numerous technological innovations have improved upon it. Many of these operations use computer-based image guidance, a technology that works as a GPS system to help guide the surgeon during the operation. Balloon sinuplasty is another tool that may be used during sinus surgery.

Sandra Butcher (second from right) and her family at a 5K run.

Some patients try complementary and alternative medicine treatments for CRS. Citardi advises caution, since many of those treatments are not only unstudied but potentially impure. And substituting unstudied treatments for more tried-and-true approaches can rob the patient of opportunities to get better.

“I have seen patients who spend thousands of dollars each month on alternative medicines, and then they come back worse than ever before,” Citardi says. He suggests that patients trying alternative treatments at least keep their doctors in the loop.

Back outdoors

These days, Sandra feels great. She manages her sinuses with a bedtime nasal spray. She’s sleeping flat and has stopped snoring. Zippy and Kinser are allowed back in the house. And she’s active again: she’s doing aerobics and 5K races, and on weekends she helps Larry with his lawn service.

“She’ll outdo me, mowing and everything,” Larry says.

Oh, and kickball. This coming year, Sandra, her daughters and granddaughters are all on the same kickball team. They call themselves The Chicks. And they’re undefeated.

This site is intended to provide general information only and is not intended to substitute for or be used as medical advice regarding any individual or treatment for any specific disease or condition. If you have questions regarding your or anyone else’s health, medical care, or the diagnosis or treatment of a specific disease or condition, please consult with your personal health care provider.

About Dr.
Martin
J.
Citardi

Dr. Martin J. Citardi is a professor and chair of the Department of Otorhinolaryngology-Head and Neck Surgery at UTHealth Medical School.